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Geizhals S, Shou Y, Rudnin S, Tama M, Greenstein J, Hahn B, Chacko J, Basile J, Marino J. Femoral nerve blocks versus standard pain control for hip fractures: a retrospective comparative analysis. Clin Exp Emerg Med 2024; 11:181-187. [PMID: 38286508 PMCID: PMC11237263 DOI: 10.15441/ceem.23.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/27/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control that reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures. METHODS This retrospective study included adult patients presenting to the emergency department with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period was randomly selected to represent the control group. The primary outcome was preoperative opioid requirement, assessed by morphine milligram equivalents (MMEs). RESULTS During the study period, 90 patients were included in each group. Mean preoperative MME was 10.3 (95% confidence interval [CI], 7.4-13.2 MME) for the intervention group and 14.0 (95% CI, 10.2-17.8 MME) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from emergency department triage to hospital discharge (7.2 days; 95% CI, 6.2-8.0 days) than patients who received standard care (8.6 days; 95% CI, 7.210.0 days). However, this difference was not statistically significant (P=0.09). CONCLUSION Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.
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Affiliation(s)
- Solomon Geizhals
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - You Shou
- Department of Anesthesiology, Long Island Jewish Valley Stream, Valley Stream, NY, USA
| | - Simone Rudnin
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Maria Tama
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Josh Greenstein
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Barry Hahn
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Jerel Chacko
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Joseph Basile
- Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Joseph Marino
- Department of Anesthesiology, Long Island Jewish Valley Stream, Valley Stream, NY, USA
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Goldsmith AJ, Brown J, Duggan NM, Finkelberg T, Jowkar N, Stegeman J, Riscinti M, Nagdev A, Amini R. Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates. Am J Emerg Med 2024; 78:112-119. [PMID: 38244244 DOI: 10.1016/j.ajem.2023.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. METHODS We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. RESULTS The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually. CONCLUSIONS All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.
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Affiliation(s)
- Andrew J Goldsmith
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Joseph Brown
- Department of Emergency Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Nicole M Duggan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Nick Jowkar
- University of Vermont College of Medicine, Burlington, VT, USA.
| | - Joseph Stegeman
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Matthew Riscinti
- Department of Emergency Medicine, Denver Health, University of Colorado, Denver, CO, USA.
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Richard Amini
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Gerlier C, Mijahed R, Fels A, Bekka S, Courseau R, Singh AL, Ganansia O, Chatellier G. Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial. Eur J Emerg Med 2024; 31:18-28. [PMID: 37650732 DOI: 10.1097/mej.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND IMPORTANCE Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse. OBJECTIVE To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management. DESIGN, SETTING, AND PARTICIPANTS This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage. INTERVENTION Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups. OUTCOME MEASURE AND ANALYSIS The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure. MAIN RESULTS We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3-9) vs. 15 MME (11-18)], with a consumption difference of 9 MME (95% CI: 3-14, P < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5-22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1-74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected. CONCLUSION Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.
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Affiliation(s)
| | - Rami Mijahed
- Emergency Department, Paris Saint-Joseph Hospital Group
| | - Audrey Fels
- Clinical Research Department, Paris Saint-Joseph Hospital Group
| | - Samir Bekka
- Anesthesiology Department, Paris Saint-Joseph Hospital Group
| | - Romain Courseau
- Orthopedic Surgery Department, Paris Saint-Joseph Hospital Group
| | | | | | - Gilles Chatellier
- Clinical Research Department, Paris Saint-Joseph Hospital Group, University Paris-Cité, Paris, France
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Reider L, Furgiuele D, Wan P, Schaffler B, Konda S. Anesthetic Methods for Hip Fracture. Curr Osteoporos Rep 2024; 22:96-104. [PMID: 38129371 DOI: 10.1007/s11914-023-00835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes. RECENT FINDINGS This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Furgiuele
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
| | - Philip Wan
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
| | - Benjamin Schaffler
- Department of Orthopaedic Surgery, NYU Langone Health, New York University Langone Orthopaedic Hospital, 310 East 17Th Street, Suite 1402, New York, NY, 10003, USA
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Langone Health, New York University Langone Orthopaedic Hospital, 310 East 17Th Street, Suite 1402, New York, NY, 10003, USA.
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA.
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Jerban S, Barrère V, Andre M, Chang EY, Shah SB. Quantitative Ultrasound Techniques Used for Peripheral Nerve Assessment. Diagnostics (Basel) 2023; 13:956. [PMID: 36900101 PMCID: PMC10000911 DOI: 10.3390/diagnostics13050956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
AIM This review article describes quantitative ultrasound (QUS) techniques and summarizes their strengths and limitations when applied to peripheral nerves. METHODS A systematic review was conducted on publications after 1990 in Google Scholar, Scopus, and PubMed databases. The search terms "peripheral nerve", "quantitative ultrasound", and "elastography ultrasound" were used to identify studies related to this investigation. RESULTS Based on this literature review, QUS investigations performed on peripheral nerves can be categorized into three main groups: (1) B-mode echogenicity measurements, which are affected by a variety of post-processing algorithms applied during image formation and in subsequent B-mode images; (2) ultrasound (US) elastography, which examines tissue stiffness or elasticity through modalities such as strain ultrasonography or shear wave elastography (SWE). With strain ultrasonography, induced tissue strain, caused by internal or external compression stimuli that distort the tissue, is measured by tracking detectable speckles in the B-mode images. In SWE, the propagation speed of shear waves, generated by externally applied mechanical vibrations or internal US "push pulse" stimuli, is measured to estimate tissue elasticity; (3) the characterization of raw backscattered ultrasound radiofrequency (RF) signals, which provide fundamental ultrasonic tissue parameters, such as the acoustic attenuation and backscattered coefficients, that reflect tissue composition and microstructural properties. CONCLUSIONS QUS techniques allow the objective evaluation of peripheral nerves and reduce operator- or system-associated biases that can influence qualitative B-mode imaging. The application of QUS techniques to peripheral nerves, including their strengths and limitations, were described and discussed in this review to enhance clinical translation.
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Affiliation(s)
- Saeed Jerban
- Department of Radiology, University of California, San Diego, CA 92093, USA
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Orthopaedic Surgery, University of California, San Diego, CA 92093, USA
| | - Victor Barrère
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Orthopaedic Surgery, University of California, San Diego, CA 92093, USA
| | - Michael Andre
- Department of Radiology, University of California, San Diego, CA 92093, USA
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Eric Y. Chang
- Department of Radiology, University of California, San Diego, CA 92093, USA
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Sameer B. Shah
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Orthopaedic Surgery, University of California, San Diego, CA 92093, USA
- Department of Bioengineering, University of California, San Diego, CA 92093, USA
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Floyd SB, NcGarby S, Cordero Romero S, Garrison S, Walker K, Hendry W, Moschella PC. Emergency Department Alternatives to Opioids: Adapting and Implementing Proven Therapies in Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1206. [PMID: 36673962 PMCID: PMC9858618 DOI: 10.3390/ijerph20021206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
The use of opioids to treat pain can increase the risk of long-term opioid dependency and is associated with negative patient outcomes. The objective of this study was to present the initial results following the implementation of Emergency-Department Alternatives to Opioids (ED-ALTO), a program that encourages the use of non-narcotic medications and procedures to treat pain in the Emergency Department (ED). We used a pre- and post-implementation study design to compare in-ED opioid utilization, as well as ED-ALTO medication and procedure use in the year before and after the program's implementation. After ED-ALTO's implementation, there was a decrease in opioid utilization in the ED and an increase in ED-ALTO medication use. Additionally, there was an increase in ED-ALTO procedure utilization and the complexity of conditions treated with ED-ALTO procedures, including the use of regional nerve blocks for shoulder dislocations and hip and rib fractures. In 8 of the 12 months following ED-ALTO's implementation, a lower proportion of patients receiving ED-ALTO procedures received an opioid, and the opioid dosage was lower compared to patients with the same diagnoses who received standard care. The continued expansion of ED-ALTO programs across the US may serve as a mechanism to reduce opioid utilization and safely and successfully treat pain in ED settings.
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Affiliation(s)
- Sarah B. Floyd
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA
| | - Sam NcGarby
- Department of Emergency Medicine, Prisma Health-Upstate, Greenville, SC 29605, USA
| | - Susan Cordero Romero
- Department of Emergency Medicine, Prisma Health-Upstate, Greenville, SC 29605, USA
| | - Sam Garrison
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA
| | - Kevin Walker
- Division of Pain Management, Prisma Health-Upstate, Greenville, SC 29605, USA
| | | | - Phillip C. Moschella
- Department of Emergency Medicine, Prisma Health-Upstate, Greenville, SC 29605, USA
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Tsai TY, Yeh HT, Liu YC, Lee CH, Chen KF, Chou E, Sun JT, Chen KC, Lee YK, Chau SW. Trends of Regional Anesthesia Studies in Emergency Medicine: An Observational Study of Published Articles. West J Emerg Med 2022; 23:878-885. [DOI: 10.5811/westjem.2022.8.57552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/27/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Regional anesthesia (RA) has become a prominent component of multimodal pain management in emergency medicine (EM), and its use has increased rapidly in recent decades. Nevertheless, there is a paucity of data on how RA practice has evolved in the specialty. In this study we sought to investigate how RA has been implemented in EM by analyzing trends of published articles and to describe the characteristics of the published research.
Methods: We retrieved RA-related publications from the SciVerse Scopus database from inception to January 13, 2022, focusing on studies associated with the use of RA in EM. The primary outcome was an analysis of trend based on the number of annual publications. Other outcomes included reports of technique diversity by year, trends in the use of individual techniques, and characteristics of published articles. We used linear regression analysis to analyze trends.
Results: In total, 133 eligible publications were included. We found that overall 23 techniques have been described and results published in the EM literature. Articles related to RA increased from one article in 1982 to 18 in 2021, and the rate of publication has increased more rapidly since 2016. Reports of lower extremity blocks (60.90%) were published most frequently in ranked-first aggregated citations. The use of thoracic nerve blocks, such as the erector spinae plane block, has increased exponentially in the past three years. The United States (41.35%) has published the most RA-related articles. Regional anesthesia administered by emergency physicians (52.63%) comprised the leading field in published articles related to RA. Most publications discussed single-shot (88.72%) and ultrasound-guided methods (55.64%).
Conclusion: This study highlights that the number of published articles related to regional anesthesia in EM has increased. Although RA research has primarily focused on lower extremity blocks, clinical researchers continue to broaden the field of study to encompass a wide spectrum of techniques and indications.
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Affiliation(s)
- Tou-Yuan Tsai
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Department of Emergency Medicine, Chiayi, Taiwan; Tzu Chi University, School of Medicine, Hualien, Taiwan
| | - Hsin-Tzu Yeh
- Chang Gung Memorial Hospital, Linkou Branch, Department of Emergency Medicine, Taoyuan, Taiwan
| | - Yu-Chang Liu
- Chi Mei Medical Center, Department of Emergency Medicine, Tainan, Taiwan
| | - Ching-Hsing Lee
- Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Department of Emergency Medicine, Keelung, Taiwan
| | - Kuan-Fu Chen
- Chang Gung University, Clinical Informatics and Medical Statistics Research Center, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Community Medicine Research Center, Keelung, Taiwan; Chang Gung Memorial Hospital, Department of Emergency Medicine, Keelung, Taiwan
| | - Eric Chou
- Baylor Scott & White All Saints Medical Center, Department of Emergency Medicine, Fort Worth, Texas; Baylor University Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Jen-Tang Sun
- Tzu Chi University, School of Medicine, Hualien, Taiwan; Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Kuo-Chih Chen
- Taipei Medical University, Shuang Ho Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Yi-Kung Lee
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Department of Emergency Medicine, Chiayi, Taiwan; Tzu Chi University, School of Medicine, Hualien, Taiwan
| | - Su Weng Chau
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Department of Emergency Medicine, Chiayi, Taiwan; Tzu Chi University, School of Medicine, Hualien, Taiwan
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